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Queen Elizabeth Hospital announces sentinel event
The following is issued on behalf of the Hospital Authority:

     The spokesperson for Queen Elizabeth Hospital (QEH) made the following announcement today (March 10) regarding a sentinel event:

     A 54-year-old woman suffering from severe headache, drowsiness and vomiting attended the Accident and Emergency Department of Tseung Kwan O Hospital in the night on March 7. The patient was diagnosed with severe intracranial haemorrhage and hydrocephalus, and therefore was immediately transferred to the QEH Neurosurgery Department for further treatment. The patient was in serious condition upon admission to QEH, and the medical team closely monitored her condition and provided appropriate treatment.

     In the morning on March 8, the patient underwent a computed tomography (CT) angiogram. The images showed that she had aneurysm with bleeding on the right side of the brain, causing an increase in intracranial pressure. As the patient was in a critical and life-threatening condition, a neurosurgeon explained the situation to the patient's family and obtained their consent, and then immediately arranged an urgent craniotomy. The neurosurgeon, in light of the preliminary CT angiogram images available that time, proceeded to remove a bone flap on the left side of the skull inadvertently to drain the cerebrospinal fluid to release high intracranial pressure.

     During the operation, an anaesthetist reviewed the detailed CT angiogram report prepared by the Radiology and Imaging Department, which indicated the aneurysm was located in the right brain. The anaesthetist immediately alerted the neurosurgical team. The team then reviewed the findings and rectified the procedures. The neurosurgeon immediately placed back the bone flap on the left side of the skull while another neurosurgeon performed a right craniotomy. The neurosurgical team explained the situation to the patient's family in the afternoon on the same day. The operation continued and was completed by around 11pm on the same day. The operation involved the drainage of the patient's cerebrospinal fluid and removal of the blood clots. A clipping of aneurysm was also performed. The patient is still hospitalised and is in stable condition.

     The hospital will continue to closely communicate with the patient and her family to provide the necessary assistance. After initial investigation, the hospital noted that the medical team had provided prompt clinical treatment to the patient. The hospital will closely monitor the patient and provide appropriate treatment. QEH apologised to the patient and will investigate the incident to prevent similar recurrence in future. The incident has been reported to the hospital management and the Hospital Authority Head Office (HAHO) via the Advance Incident Reporting System. A Root Cause Analysis Panel will be formed soon and the report is to be submitted to the HAHO in eight weeks.
Ends/Friday, March 10, 2017
Issued at HKT 18:53
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